Provider Demographics
NPI:1518631050
Name:WILLIS, ADRIENNE CHRISTINA (LMT)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:CHRISTINA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 E 233RD ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-2226
Mailing Address - Country:US
Mailing Address - Phone:914-458-2725
Mailing Address - Fax:
Practice Address - Street 1:93 E 233RD ST APT 3R
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-2226
Practice Address - Country:US
Practice Address - Phone:914-458-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030753-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist